Healthcare Provider Details

I. General information

NPI: 1144458647
Provider Name (Legal Business Name): CRESTVIEW URGENT CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 S FERDON BLVD
CRESTVIEW FL
32536-8444
US

IV. Provider business mailing address

1502 S FERDON BLVD
CRESTVIEW FL
32536-8444
US

V. Phone/Fax

Practice location:
  • Phone: 850-398-1079
  • Fax:
Mailing address:
  • Phone: 850-398-8668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberME93880
License Number StateFL

VIII. Authorized Official

Name: CHARLES JOSEPH CLANCY
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 850-398-8668